Provider Demographics
NPI:1235463308
Name:JACKSON, JAMILLAH A (MS/EDS, NCC, LPC)
Entity Type:Individual
Prefix:MS
First Name:JAMILLAH
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS/EDS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 EMPEROR BLVD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-8577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 EMPEROR BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-8577
Practice Address - Country:US
Practice Address - Phone:919-651-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NC8340101YP2500X, 101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8340OtherTHE NC BOARD OF LICENSED PROFESSIONAL COUNSELORS
246803OtherNATIONAL BOARD FOR CERTIFIED COUNSELORS, INC.